Dalbavancin as an alternative to traditional outpatient parenteral antimicrobial therapy for deep gram-positive infections - an observational, retrospective review.

Background: Treatment of invasive gram-positive infections in complex patient populations is challenging. Dalbavancin, approved for skin and soft tissue infections, offers advantages in this setting due to its long half-life and infrequent dosing. However, less is known about the outcomes of off-label dalbavancin for deeper infections. Objectives: The objective of this study is to examine the feasibility and outcomes of patients with complex gram-positive infections treated with dalbavancin as an alternative to standard outpatient parenteral antimicrobial therapy (OPAT). Methods: We conducted a multicenter, retrospective review of adult patients managed within an OPAT program with intravenous dalbavancin for off-label indications. Adult patients were included if they had treatment details and follow-up documented between January 2020 and June 2023. Details of dalbavancin use including indications for prescription were captured. Outcomes of interest included 90-day infection recurrence, prosthesis retention rates, 90-day mortality, and adverse medication events. Results: In all, 61 patients received dalbavancin, mostly as sequential therapy. Twenty-three percent received dalbavancin strictly in the outpatient setting. Dalbavancin was used primarily for hardware (fracture, spine, or joint), native bone or joint, and complicated soft tissue infections. The predominant pathogen was Staphylococcus aureus (61%). Dalbavancin was frequently prescribed as a two-dose 1500 mg regimen (49%) due to persistent infection (23%), difficult line access (30%), difficulty achieving therapeutic vancomycin levels (18%), or substance abuse history (18%). Overall, six patients (10%) had infection recurrence and no patients died during the follow-up period. Three of eight patients with hardware retention had infection recurrence. Adverse effects were minimal and mostly self-limiting. Conclusion: Dalbavancin is an efficacious and safe alternative to standard OPAT, especially in those with barriers to traditional long-term intravenous antibiotics. Improved outcomes may be achieved with hardware removal. Dalbavancin may facilitate early discharge or prevent hospitalizations. Comparative studies of standard OPAT regimens versus dalbavancin are needed.

Eosinophilic Enteritis Flare-Up Mimicking Acute Gastroenteritis: A Rare Case.

Eosinophilic enteritis is a rare subset of eosinophilic gastrointestinal disorders. It typically presents with chronic symptoms of abdominal pain, nausea, vomiting, diarrhea, and ascites. However, the clinical presentation can vary due to acute flare-ups. Here, we present a case of eosinophilic enteritis in a young female patient with intractable vomiting and diarrhea, mimicking acute gastroenteritis in the absence of other gastrointestinal symptoms. This case illustrates the challenge of diagnosing acute and diverse presentations of eosinophilic enteritis. It also highlights the importance of promptly treating and confirming the diagnosis through urgent tissue histopathology in adolescents with unexplained vomiting and diarrhea.

Moyamoya Disease: A Review of Current Literature.

Moyamoya disease (MMD) is an infrequent disease of cerebral vasculature characterized by long-standing and progressive occlusion of large intracranial arteries. It is seen predominantly in the East Asian population. Most of the cases of MMD are sporadic, but there is a small percentage that is familial. The mode of inheritance is reported to be autosomal dominant with incomplete penetrance. Studies show that the susceptibility gene of MMD is located on chromosome 17. The clinical presentation is variable and is influenced by the age and geographic region of the patient. Children mainly present with ischemia-related neurologic episodes whereas MMD in adults can manifest as either an ischemic event or an intracranial hemorrhage (ICH). The gold standard investigation for diagnosis is cerebral angiography which reveals a smoky appearance of arteries at the base of the skull, thus granting the disease its name. The treatment is mostly surgical and includes direct and indirect revascularization procedures, which prevent the recurrence of both ischemic and hemorrhagic strokes. However, combination revascularization procedures are now on the rise due to studies showing better long-term outcomes. The aim of the article is to critically analyze the current literature and updates on various aspects of MMD including, but not limited to, etiology, diagnosis, and treatment.

A Complication of Pneumothorax and Pneumomediastinum in a Non-Intubated Patient With COVID-19: A Case Report.

COVID-19 disease can lead to multiple complications such as severe acute respiratory distress syndrome (ARDS), coagulopathy, renal failure, cardiac and neurological complications. We describe a case of a patient who developed pneumothorax and pneumomediastinum in the setting of COVID-19 without having ARDS or requiring mechanical ventilation. Our patient developed sudden onset of shortness of breath and desaturation. Chest X-ray and CT chest revealed pneumothorax and pneumomediastinum. Though pneumothorax in pulmonary infection is most likely associated with increased airway pressure in acute respiratory distress syndrome and positive pressure mechanical ventilation. Pneumothorax is a life-threatening complication and if diagnosed early it can reduce mortality. In patients with COVID-19 infection, sudden clinical worsening with shortness of breath and desaturation should prompt the clinician to look for potentially treatable causes such as pneumothorax.

A Rare Case of Acute Cord Compression From Spinal Myeloid Sarcoma: A Complication of Acute Myeloid Leukemia.

Acute myeloid leukemia (AML) is the most common malignancy in the acute leukemia category. AML is a very aggressive cancer with high mortality. The most common presentations include pancytopenia, bleeding, and recurrent infections. Unlike lymphoma, it rarely presents as a mass. Myeloid sarcoma is a peripheral collection of myeloid cells. Myeloid sarcoma most commonly involves the skin and gingival tissue and rarely it affects the central nervous system. Myeloid sarcoma involving the central nervous system is associated with high mortality. We present a patient with AML which evolved from myelofibrosis presented with acute spinal cord compression and found to have myeloid sarcoma involving the thoracic spinal cord. Despite acute radiation therapy, the patient could not recover her neurological function and passed away shortly after the diagnosis. We discuss the importance of early recognition of the complication due to myeloid sarcoma and treatment with neurosurgical intervention just like other mass causing acute cord compression.

Intracranial hemorrhage complicating anticoagulant prophylactic therapy in three hospitalized COVID-19 patients.

SARS-CoV2 has led to a global pandemic affecting almost 3 million people in almost over 3 months. Various clinical presentations have been reported so far and no definite therapy is established. Anticoagulation is recommended by several experts to address the potential prothrombotic complications from COVID-19, but its safety and regimen need further clinical trials and safety and efficacy profile. Here, we present three cases of intracranial hemorrhage in three critically ill patients with COVID-19 and discuss their course in relation to various regimens of anticoagulation used.